C Section vs. Regional Flashcards
Most common Indications for C section (4)
- previous C section ( #1 cause)
- dystocia
- malpresentation
- non-reassuring fetal status
Indication and benefit for midline vertical skin incision
- “super STAT emergencies”
- Provides faster and better surgical exposure/ visualizations
Benefits of Horizontal suprapubic skin incision
- you can wear a bikini ( cosmetics )
- better wound strength
Indications for Verticle uterine incision (5)
- lower uterine segment underdeveloped (<34wks)
- delivery of preterm infant in a parturient who has not labored
- multiple gestation
- malpresentation
- low lying anterior placenta previa
Uterine Exteriorization risks/cons (5)
- higher rate of N&V
- increased risk of venous air embolus
- increased pain
- controversial effects on blood loss and infection
- chest pain
Number one complication of C-section
Hemorrhage
Complications of C section (7)
- hemorrhage
- infection
- thromboembolism
- ureteral and bladder injury
- abd pain (i feel like this goes without saying but whateves)
- uterine rupture in subsequent pregnancies
- death
Does neuraxial anesthesia increase the rate of cesarean deliveries
nah
Can adequate labor analgesia help avoid cesarean deliveries
yup
Breech position occurs in what % of singleton pregnancies
3-4%
this is dumb but I aint taking any chances this time around
Why should vaginal breech delivery be done with extreme caution?
increased risk of emergency section and neonatal injury
Neuraxial anesthesia improves the success rate of ECV by __% w/o increased rate of fetal distress
50%
When is ECV typically performed
36-37 weeks
What contributes to the likelihood of successful ECV (5)
- normal weight
- normal amniotic fluid volume
- presenting part not yet in pelvis
- fetal back is not posterior
- frank breech or transverse position
Common complications of ECV
- transient or persistent FHR abnormalities
- vaginal bleeding
- placental abruption
- emergency c section
- still birth
What block will improve the success rate of ECV
high T6-T4 dense neuraxial block
For ECV neuraxial what determines SAB v. epidural?
- SAB if pt to discharge
- epidural if planning to labor
Intrauterine Resuscitation components (6)
- optimize maternal position
- oxygen
- rapid IV bolus of non-dextrose fluids
- treat hypotension with ephedrine or phenylephrine
- discontinue Pitocin
- consider starting tocolytic
What should be included/asked about in pre-anesthetic evaluation for pregnant ppl?
- history (diabetes, preeclampsia)
- previous pregnancies & any complications
- MH susceptibility for mom and dad
- epidural history
- birth plan
When should anesthesia evaluation ideally occur
late 2nd or early 3rd trimester for high risk patients
What are the most common sources of influence to a mother in regards to labor analgesia
-friends, family, and Facebook bby
Should you inform your patient with language they understand and can comprehend
no shit MBG
Threshold elements of informed consent
the patient is competent (able to make sound medical decisions for themselves)
Information elements of informed consent
- provider discloses information about material risks
- patient understands information
consent elements of informed consent
- provider offers information in a noncoercive manner
- patient gives authorization voluntarily
How often should maternal BP be cycled?
at least q5min
q2 mins after spinal
Should blood admin consent be included in the informed consent discussion?
yup
Order of blood loss from vag, c sec, c sec during labor from most to least
C-section during labor >> uncomplicated/planned C-section > uncomplicated vaginal delivery
healthy patients for elective c section may drink modest amounts of clear fluids up to __ hrs prior to induction
2 hrs
What is more important than volume in regards to aspiration prophylaxis in preggos
absence of particulates
How long should ingestion of solid foods be avoided in laboring patients
6-8hrs
Sodium citrate has what effect on pH
increases it
H2 receptor antagonists, PPIs, and metoclopramide help reduce the likelihood of aspiration by?
What is the onset time?
reducing gastric acid secretion and volume
30-40min
how soon is it recommended to begin a narrow-spectrum antibiotic after the start of a c section
within one hour
What antibiotic is often used for c sections
first-generation cephalosporin
If the patient has a beta-lactam allergy what antibiotic is used
clindamycin and gentamycin
When should higher dose antibiotics be considered
- BMI >30
- absolute weight > 100kg
It is okay to administer low dose benzo to help with anxiety
yes, may aid in neuraxial technique, lessen the risk of PTSD, and low doses have minimal to no effect on baby
After how many weeks gestation should all mamas be placed in left uterine displacement
20 weeks gestation
What position may help reduce the incidence of hypotension after initial hyperbaric spinal analgesia
slight (10 degree) head-up position
What position can significantly improve FRC
head up 30 degrees
What position may augment venous return and cardiac output but also may result in more cephalad spread of anesthesia
Trendelenburg
Which position for neuraxial minimizes the prominence of dural sac and decreases the severity/duration of hypotension
lateral position
When should sitting position for neuraxial insertion not be used?
- fetal head entrapment
- umbilical cord prolapse
- footling (?) breech presentation
Potential benefits of supplemental oxygen with neuraxial
Is it currently still recommended
- better oxygenation (shocker)
- better umbilical cord acid-base balance
- less time to sustained respiration of neonate
unclear, seems dumb. conflicting research
Indications for Neuraxial Anesthesia(4)
- mother request
- difficult airway or aspiration risk
- comorbidities
- GA intolerance
Benefits of neuraxial anesthesia
- can utilize neuraxial analgesia after surgery
- less fetal drug exposure
- less blood loss
- allows the presence of support person
Indications for GA
- maternal refusal/uncooperative with neuraxial
- contraindications to neuraxial (coagulopathy, site infection, LA allergy)
- sepsis
- severe hypovolemia
- intracranial mass with increased ICP
- fetal issues
- not enough time for neuraxial
Advantages of epidural
- no dural puncture is required
- ability to titrate
- continuous post-op analgesia
disadvantages of epidural
- slow onset
- larger dose required
- greater risk of toxicity and for fetal exposure
advantages of CSE
- technically easier in obese than spinal
- low dose
- rapid onset of dense block
- ability to titrate
- continuous intra-op anesthesia
- continuous post-op analgesia
disadvantages of CSE
delayed verification of functioning epidural
One shot spinal advantages
- low dose
- fast onset of dense lumbosacral and thoracic anesthesia
one shot spinal disadvantages
- limited duration
- unable to titrate extent of block
continuous spinal advantages
- low dose
- rapid onset of dense block
- titratable
- continuous intraop anesthesia
continuous spinal disadvantages
- larger dural puncture increases the risk of PDPH
- possibility of overdose and total spinal
What is the most common anesthesia technique for C section
Spinal Anesthesia (SAB)
Which bevel is rarely used and associated with a higher incidence of PDPH
Cutting bevel
Which bevels are almost exclusively used
non-cutting ( “pencil point”)
Sprotte or Whitacre (Won’t Shear) :)
Larger or smaller needles are more likely to withstand high resistance without damage?
larger needles
Introducer needles are necessary for larger needles, smaller needles, or both?
smaller only
Which SAB approach is typically less painful for the patient
Midline approach
Which SAB approach is typically faster
Midline
Which approach requires more patient cooperation with positioning
Midline
With the paramedian approach are you still trying to puncture the dura at the midline
yup
are lower doses of central blocks used for pregnant v. nonpregnant patients? Why?
yes
-smaller CSF volume, greater sensitivity, cephalad movement
What LA is the predominant agent for SAB for Cesarean delivery
Bupivicane
Bupivacaine dose range
*from chart on slide 49
7.5-15mg
Bupivacaine SAB duration
*from chart on slide 49
60-120min
fentanyl dosing for SAB
*from chart on slide 49
10-25 mcg
fentanyl duration as SAB adjuvant
*from chart on slide 49
180-240min
benefits of opioid admin with SAB
- improve comfort intra-op and postop
- decreases need for intra-op opioids
Is 20mcg of fentanyl superior to 4mg of ondansetron in the prevention of intra-op vomiting during cesarean
yup
T/F - Fentanyl as an adjuvant agent in a spinal block leads to increased need for postop opioids after 4 hours
False -
Increased need after 6 hours
(Reworded this to make it tricky bc she loves stupid numbers)
Advantage of small dose (15-35mcg) vs. large dose fentanyl(45-65mcg) as an adjuvant to a spinal block
decreased pruritus, nausea, and vomiting in a SMALLER dose
which SAB adjuvant is more effective for prolonged postop analgesia - fentanyl or preservative-free morphine?
how long is analgesia provided?
morphine - 12-24 hours
T/F occurrence of pruritis with preservative-free morphine in a SAB is NOT dose-dependent
false, it is dose-dependent
is N/V associated with preservative-free morphine dose-dependent
nope
Purpose of adding dextrose to SAB
make a hyperbaric solution
purpose of adding epi to SAB
- increases density of motor blockade
- may prolong the duration
benefits of adding clonidine to SAB (3)
- improves analgesia
- decreases shivering
- reduces peri-incisional hyperalgesia
Black box warning for spinal clonidine in OB patients
bc of concerns with hemodynamic instability
**given anyways, so don’t let her trick you on the next test **
Neostigmine use in SAB has shown a decrease in postop pain BUT what negative side effect limits its usefulness
nausea
How does neostigmine in SAB affect FHT or Apgar scores?
it doesn’t
Why is the use of epidural anesthesia for elective cesarean delivery becoming less common (4)
- block less reliable
- higher doses (5-10 times)
- greater systemic absorption increases risk of LA toxicity
- slower onset
most common LA for initiation and maintenance of epidural for cesarean
2% Lidocaine with epi
Which LA results in the most rapid onset and shortest duration
3% 2-chloroprocaine
which LA is associated with rapid onset of hypotension and reduced clinical efficacy if administered with opioids
3% 2-chloroprocaine
Can you add fentanyl, sufentanil, clonidine, neostigmine, or epi to an epidural?
yup
*she provided no life-changing info on how the effects of these being added to an epidural is any different from a spinal. she listed the same things so see book decks for more info (hopefully)
when is the use of epi in an epidural controversial
preeclamptic women
the benefit of adding sodium bicarb to epidural
- more non-ionized molecules, speeds onset
- improves quality
Combines the rapid and predictable onset of a spinal with the ability to titrate with the epidural catheter
Combined spinal-epidural (CSE) anesthesia
Extension of a T10 level of analgesia to T4 level anesthesia requires how much local with one or more adjuvants
15-20ml
how does the prep and drape process for a c section differ from general abdominal surgery?
prep and drape occurs BEFORE induction of GA
What type of induction is required for all preggos
RSI following preoxygenation
what is typically used for induction (agent + dose) in cesarean GA cases
propofol 2-2.8mg/kg
in the case of hemodynamic instability what agent(s) are typically substituted for propofol
Ketamine 1-1.5mg/kg
Etomidate 0.3mg/kg
Which NMBs and dose are used for induction
Succinylcholine 1-1.5mg/kg
Roc 1mg/kg
What size ETTs are typically used to intubate pregnant women
6-6.5 with semirigid stylet
If an airway is difficult should you follow the difficult airway algorithm
i know this is SHOCKING, but yes
Indications for GA
- coagulopathy
- infection at the insertion site
- sepsis
- severe hypovolemia
- known allergy to LA
- intracranial mass with increased ICP
- failure of neuraxial technique
- fetal issues
- inefficient time for neuraxial
*THE SAME EFFING LIST SHE PUT IN HERE LIKE 5 TIMES but here it is again folks
ETCO2 goal for a pregnant momma during GA
30-32mmHg
Excessive ventilation of pregnant mom can cause uteroplacental vasoconstriction and shift the oxyhemoglobin dissociation curve to the __
to left to the left
Is there a particular inhalation agent preferred for GA for cesarean
nope, none are superior to others for these cases
what MAC may reduce the effect of oxytocin on uterine tone > blood loss
1-1.5 MAC
When are opioids typically delivered during GA cesarean
given after the cord is clamped
adverse effects of U-D interval longer than 180 seconds
lower Apgar scores and fetal pH
How long postpartum are women considered full stomachs
6 weeks postpartum
position for emergence and extubation
semirecumbent
majority of deaths with GA due to what during emergence
hypoventilation or airway obstruction
Does thiopental cross the placenta?
yuppp
Do induction doses of thiopental 4mg/kg achieve fetal brain threshold for neonatal depression
rarely, but large doses 8mg/kg can
what allows for the mother to be unconscious and the neonate be awake when thiopental is used (4)
- preferential uptake of thiopental by the fetal liver
- higher relative water content of the fetal brain
- rapid redistribution to maternal tissues
- nonhomogeneity of blood flow in intervillous space
- progressive dilution by admixture with various components of fetal circulation
Does propofol result in higher or lower Apgar scores compared to thiopental
lower
what induction agent has a higher incidence of maternal hypotension
propofol
does propofol cross the placenta
yup
Which agent should you choose for urgent deliveries in a patient with hypotension or acute asthma exacerbation
Ketamine due to its sympathetic properties
When is ketamine not recommended
preeclampsia
the use of etomidate as an induction agent is ideal for what situations (2)
- hemodynamic instability
- severe CV disease
What effect does etomidate have on neonatal cortisol production
transient reduction
side effect associated with the use of etomidate
nausea and vomiting
why is versed often avoided
amnestic properties
dose of succs to intubate mom
1-1.5mg/kg
intubating conditions in how many seconds after sux
45seconds
does sux cross the placenta
only trace amounts
What dose of sux would allow for placenta transfer and result in sufficient fetal weakness
10mg/kg
Roc dose
0.6mg/kg = ideal intubating conditions in ~79 seconds (eye roll)
also has 1 mg/kg in this ppt? so in conclusion, unclear
ideal intubating conditions in how many seconds after 0.6 mg/kg roc
79 seconds
does roc have an effect on Apgar scores
no
Vec dose
0.1mg/kg
Vec onset
144seconds
Why is atracurium a less desirable agent for RSI (3)
- high doses required
- histamine release
- hypotension
What effect does nitrous have of maternal BP
minimal
What effect does nitrous have on uterine tone?
minimal
does nitrous cross the placenta
yup
what is seen more often in neonates when exposed to nitrous
need for resuscitation
what effect do volatiles have on the uterine tone
decreases
At what MAC are oxytocin-induced contractions completely inhibited
2 MAC
metabolite for meperidine
normeperidine
effect of the build-up of normeperidine
- can build up in both mother and baby
- results in respiratory and neurobehavioral alterations
MH is what kind of inherited gene
inherited autosomal dominant
Is malignant hyperthermia more prevalent in the pregnant population
nope, v v rare
When is oral intake recommended post-cesarean
within 4-8hrs
Risk factors for urinary retention (3)
- post-op opioid analgesia
- multiple gestation
- low BMI
Symptoms of high neuraxial block (5)
- impaired phonation
- unconsciousness
- respiratory depression
- bradycardia
- hypotension
Does prewarming before neuraxial help limit the reduction in temp
epidural- yes
spinal - no
When is the pregnant patient at highest risk for developing an embolus
the first week postpartum
prophylaxis for embolus (4)
- hydration
- early mobilization
- pneumatic compression devices
- pharmacologic in high-risk patients
benefits of horizontal uterine incision (4)
- less incidence of uterine rupture
- lower infection risk
- decreased blood loss
- decreased risk for adhesions
